Prof. Hani Hamed Dessoki, M.D.PsychiatryProf. Hani Hamed Dessoki, M.D.PsychiatryProf. PsychiatryProf. Psychiatry

Chairman of Psychiatry DepartmentChairman of Psychiatry Department

Beni Suef UniversityBeni Suef University

Supervisor of Psychiatry DepartmentSupervisor of Psychiatry Department

El-Fayoum UniversityEl-Fayoum University

APA memberAPA member

Psychiatric EmergenciesUnderstanding

Psychiatric Emergencies

Due to the heterogeneity of the subjects, there are no consistent

guidelines even for evaluation

In cases of risk of harm to self or others coupled with pathological mental status, documentation of

your reasoning becomes all important.

PSYCHIATRIC EMERGENCY

• Conditions need immediate interventions & any delay increase risk for patients and others

• One of the most Pitfall in Psychiatric Emergency is NEGLECT & IGNORE of ORGANIC CAUSALITY in Emotional Disorders

Psychiatric Disorders

• Important to exclude medical causes of behavioral problems before concluding they are psychiatric.

History

• Since the 1960s the demand for emergency psychiatric services has endured a rapid growth due to deinstitutionalization both in Europe and the United States.

• There have been increases in the number of medical specialties, and the multiplication of transitory treatment options, such as psychiatric medication.[

PSYCHIATRIC EMERGENCY

• SUICIDE & HOMICIDE

• AGGRESSION & VIOLENCE

• CATATONIA

• NMS (Neuroleptic Malignant Syndrome)

Psychiatric Emergencies

• TCAs

• Neuroleptic malignant syndrome

• Serotonergic syndrome

• Anticholinergic psychosis

PSYCHIATRIC EMERGENCY

• Prevalence:

%20 of referrals; Suicidal

%10 of referrals; Aggressive or Violency Behavior

%40 of ALL Referrals need Hospitalization• Male= Female

• Single> Married• Often Night Time

Epidemiology

• Equals 5 to 7 % of all emergencies

• More males

• Seasonal variations

Seasonal Variations

• Spring: Organic, Affective, Schizophrenic

• Summer: Schizo & Adjustment

• Winter: Drug Induced

• No peak for personality disorder

Keys

• Awareness of potential scenarios

• Familiarity with appropriate interventions

• Understand patient rights and legal issues

Psych EmergenciesRequirements

• Calm, objective assessment

• Swift, decisive action

PSYCHIATRIC EMERGENCY

• Clinical Evaluation:

FIRST : Emergency Interventions

THEN: Diagnosis & Treatment of Major Disease

SUICIDE

• Suicidal Thought

• Suicidal Threat

• Suicidal Attempt: F >M

• Committed Suicide: M>F

Assessment of Suicide Risk- Some Statistics

• 31,000 deaths each year – US

• 9th leading cause of death – US

• 3rd leading cause of death 15 – 25 year olds – US

SUICIDE

• Psychiatric Disorder:

MDD, Dysthymia, BMD

Schizophrenia, Schizophreniform, Brief Psychotic Disorder

PTSD,OCD,GAD

Personality Disorders

SUICIDE

• Medical Problems:CNS Disease (Epilepsy, MS, AIDS, Dementia,

Hantington)Endocrine (Cushing Disease, Anorexia Nervosa,

Kleinfelter)GI (Peptic Ulcer, Cirrhosis)

Immobility , Disfigurement , Persistent Chronic Pain

SUICIDE

ETIOLOGY• Biologic

Serotonergic Hypofunction, Platlet MAO decrease

,Genetic• Psychologic

Hoplessness, Depression, Impulsivity, Aggressivity• Social

Family Discord ,Divorce, Single, Lack of Support

SUICIDE

HIGH RISK SUICIDE:• Male• >45 Yrs old• Single & Divorce• Unemployment• Unstable Family & Interpersonal Relationship• Severe Depression, Psychosis, Personality

Disorder, Substance Use (Alcohol)

SUICIDE

HIGH RISK SUICIDE

• Hopelessness

• Prolonged & Severe Suicidal Thought

• HX of Several Attempts, with Plan, Low Rescue, Use of Fatal Methods

Assessment of Suicide Risk- Assessment

• Clinical suspicion

–Stated ideation

–Risk Factors

Risk Factors for Suicide

• Major depression• Alcoholism• History of suicide

threats/attempts• Male gender• Increasing age• Substance abuse• Widowed or never

married

• Unemployed and unskilled

• Chronic illness or pain• Terminal illness• Guns in the home• Family history of

suicide

The BEST PREDICTOR of completed suicide is…..

A history of attempted suicide

Evaluation of Patients with Suicidal Ideation

• History of ideation

• History of attempts

• Screen for alcohol abuse

• Mini Mental Status Exam (MMSE)

• Interview the family

Assessment Questions

• Have you ever thought about hurting yourself?

• Have you thought about a way (plan)?

• Do you have a way? (means)

• Can you resist the feeling?

Be Alert for Indirect Statements:

• “I’ve had enough”

• “I’m a burden”

• “It’s not worth it”

Specific Questions to Ask about Suicidal Ideation:

• When did you begin to have suicidal thoughts?

• Did anything precipitate them?• Howe often do you have them?• What makes you feel better?• What makes you feel worse?

• Do you have a plan to end your life?

• How much control of these ideas do you have?• What stops you from killing yourself?

Questions About Plans

• Do you have a gun or access to one?

• Do you have access to harmful medications?

• Have you practiced your suicide?

• Have you changed your will or life insurance?

Asking patients about suicide does not give them

the idea!

To Hospitalize or Not…?

• Access to means

• Poor social support

• Poor judgment

• Cannot make a contract for safety

Outpatient?

• No intent nor plan

• No means, has social support and good judgment

• Can contract for safety

In Doubt on Hospitalization?

Consult psychiatry

Legal Issues

• If in imminent danger, confidentiality can be breached

• Involuntary hospitalization in most states

• Unsure? Call a crisis center.

Non-Harm Contracts• Specific and brief time (24- 48 hours)• Patient to contact provider if situation changes• Accompanied by frequent follow-up contact• Renewed at end• No credence if patient is intoxicated, psychotic,

too depressed, or made a serious attempt in the past.

• Involve the family

Assessment of Suicide Risk-Interventions, Short-Term Risk

• Intermediate follow-up

• Remove as many risk factors as possible before discharge

Treatment

• Treat depression

• Treat anxiety

• Treat insomnia

AGGRESSION & VIOLENCE

AGGRESSION

• Goal directed Behavior (verbal or nonverbal) for Hurt

VIOLENCE

• Severe & Sudden Goal directed Behavior to Destruction of property OR Hurt OR Kill others

AGGRESSION & VIOLENCE

• BMD

• Schizophrenia, Schizophreniform, Brief Psychotic Disorder

• MDD

• Personality Disorders

AGGRESSION & VIOLENCE

RISK EVALUATION:

• Demographic Characteristics: Male ,15-24 Yrs, Low SES &Social Support

• Evaluation of Thought, Attempt, Plan for Violence, Weapons Availability

• Past HX of: Violence, Antisocial Behaviors ,Impulse Control Disorder (Substance,….)

• HX of Major Stressor: Loss, Family Discord…

AGGRESSION & VIOLENCE

Impending Violence:• Verbal or Physical Threatening• Progressive Restlessness• Weapons Carrier• Substance or Alcohol Abuser

• Excited Catatonia• Paranoid (Psychosis)• Personality Disorder

Violence and AggressionOverall goals

• Ensure safety of patient and staff

• Determine whether aggression stems from psychiatric or medical disorder

• Do a medical evaluation

• Do a psychiatric assessment

• Effect appropriate treatment

• Warn third parties if they are under threat

Management of Violence

• Depends on your ability to:

–Predict violence–Reduce the threat

–Manage the setting

–Manage your reaction

Violence Decision Making Patients and Hospitalization

• Most likely need hospitalization– Referred by police or health professional– Psychosis diagnosis– Prior hospitalization– No Community programs

• Less Likely:– Defined precipitant– Good social support

Hierarchy of Assault Predictors

• Uncertain Risk – May need precautions

• Medium Risk – Requires precautions

• Imminent Danger – Requires action

Assault Predictors(Uncertain Risk)

• Threats only• Poor Insight• Dementia• Schizophrenia

• Sensory Defects• Aphasia• Head Injury

Assault Predictors(Medium Risk)

• Prior assault• Arrest record• Threats• Alcohol abuse• Verbal abuse

• Personality Disorder• Paranoid• Antisocial• Borderline• Agitation

Assault Predictors(Imminent Danger)

• Recent assault• Repeated assaults• Psychosis• Mania• Delirium

• Intoxication• Threats• Threatening body

language• Weapons

Psychiatric EmergenciesTools for Intervention

• Non- pharmacologic– Redirection/de-escalation– Restraint

• Show of force• Seclusion• Restraint

– Pharmacologic

Redirection/de-escalation

• Sit with a table between you and the patient• Make sure you both have access to the door• Avoid frustrating the patient• Avoid staring at the patient• Do not turn your back to the patient• Keep hands open and visible• Do not be judgmental

Restraint Policy

• Indications (which accounts for ”least restrictive treatment”, etc..)

• Technical issues

• Facility requirements

Restraints

• Never used as a threat

• Do not attempt without sufficient help

• Apply calmly and non punitatively

Legal Issues

• All 50 states have laws requiring involuntary detention of dangerous patients

• 1982 Supreme Court “restraints are justified to protect others or self in the judgment of the health professional.”

• Ensure restraints are not negligently used

CATATONIA

Catatonia: DSM-IV criteria

• Motor immobility as evidenced by catalepsy (including waxy flexibility) or stupor;• Excessive motor activity (purposeless, not influenced by external stimuli);• Extreme negativism (motiveless resistance to all instructions or maintenance of

a rigid posture against attempts to be moved) or Mutism;• Peculiarities of voluntary movement as evidenced by posturing, stereotyped

movements, prominent mannerisms, or prominent grimacing• Echolalia or Echopraxia.A. At least 2 of the above features B. Due to mental (eg: Schizophrenia or Mood Disorders) or medical disorderC. Does not occur exclusively during the course of a Delirium

*Gegenhalten, Mitgehen, Automatic Obedience, Ambitendency

Fink Catatonia Scale (1996): www.ukppg.org.uk/catatonia.html

Lethal Catatonia (Kahlbaum 1874)Mann et al., Amer. J. Psych. 1986; 143:11, p. 1374-81

• Classic description (Pre-neuroleptic era):– Intense motor excitement followed by hyperthermia and

exhaustion or stupor– Often prodromal phase of insomnia, anorexia, labile mood– May demonstrate catatonic signs, and be delirious-like

(disorganized thinking, psychosis, destructive)– May have rigidity, or flaccidity, in terminal stages– Fatal in 75-100%

NOROLEPTIC MALIGNANT

SYNDROM(NMS)• Fatal Complication due to Antipsychotics• Abrupt Discontinuation Levodopa in Parkinsonism• Anytime in Treatment Course• Prevalence:% .02- 2.4• Mortality Rate:%10-20

• Male>Female • Young>Geriatrics

NOROLEPTIC MALIGNANT

SYNDROM(NMS)Major Symptoms:

• Muscle Rigidity

• Increase in Body Temperature

AND 2 Symptoms of:

Diaphoresis/ Tremor/ Dysphagia/ Mutism/ Urinary Incontinency/Tachycardia/Alteration in Consciousness level/Leucocytosis/HTN/ Muscle Injury (CPK)

NEUOROLEPTIC MALIGNANT

SYNDROM(NMS)Treatment (Conservative)

• FIRST: Discontinuation of AP

• Decrease Body Temperature

• Monitoring of Vital Signs, Hydratation, Electrolyte

• Muscle Relaxant (Bromocriptine,Amantadine, Dantrolene)

FOR 5-10 DAYS

NEUOROLEPTIC MALIGNANT

SYNDROM(NMS)Prevention

• Use of AP in Appropriate Indications

• Use of AP in Minimum Effective Dose

• Use of AP with Cholinergic Properties

Take Home Message

Recent Findings

Antidepressants make shrimp act crazy

• You’ve probably heard about all the prescription meds in our water supply. Turns out Prozac in public waters makes shrimp act nutty—and not in a good way.

Seems that the active ingredient in antidepressants like Prozac boosts serotonin in the shrimps’ nervous system and make them wiggle away from safe, dark waters toward the light, where they’re more likely to be devoured by predators.

And because researchers don’t think Prozac has the same mood-elevating effect in shrimp as it does in people.

Puppies and polar bears are on Prozac

• While no one knows how many pets are on Prozac, Americans spend an estimated $15 million a year on behavioral medication for their cats and dogs.

In 2007, Eli Lilly, the maker of Prozac, launched Reconcile, a chewable form of its drug, for canine separation anxiety.

Now even zoo animals are on antidepressants, for everything from aggression to obsessive-compulsive disorder.

Questions

Slideshare Hanipsych, Psychiatric Emergencies